Sherwood Oaks Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Thousand Oaks, California.
- Location
- 250 Fairview Road, Thousand Oaks, California 91361
- CMS Provider Number
- 555794
- Inspections on file
- 65
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Sherwood Oaks Post Acute during CMS and state inspections, most recent first.
A resident with significant respiratory and neuromuscular conditions was observed using a BiPAP machine that displayed a continuous leak alarm message for an extended period without staff awareness, with the device facing the wall and its audible alarm difficult to hear. During ordered BiPAP treatment hours, the resident was instead on nasal cannula oxygen, and staff could not resolve the leak or access an operator manual, which was not available onsite despite policy requiring use of manufacturer instructions. BiPAP and oxygen orders for this resident were entered inaccurately and interpreted inconsistently by nursing staff, leading to uncertainty about required therapy times and oxygen use. In addition, two other residents had oxygen concentrators set at flow rates that did not match MD orders, and the DON could not produce required documentation of general assessments and other elements specified in the facility’s CPAP/BiPAP policy.
Surveyors found that a nebulizer mask and tubing used for PRN ipratropium-albuterol treatments for a resident with COPD exacerbation, acute and chronic respiratory failure with hypoxia, and muscular dystrophy were stored uncovered on a shelf instead of in a protective bag as required by the facility’s respiratory therapy infection prevention policy. An LVN confirmed the equipment was not properly stored per policy, and the report notes this failure had the potential to cause cross-contamination and preventable HAIs for a resident in a compromised condition.
A resident's representative was not informed of a rescheduled cardiovascular appointment, despite facility policy requiring notification of pending appointments and transportation arrangements. Documentation showed the appointment date was changed, but there was no record of notification to the responsible party, and staff confirmed this omission.
A shower room was found to be unsanitary and in disrepair, with issues such as a broken doorframe, damaged tiles, an improvised call light cord made from plastic bags, and improper storage of personal care items and sharps. These conditions were confirmed by the Maintenance Director and did not meet the facility's policy for a safe and clean environment.
Staff did not follow facility policy for labeling and storing perishable foods brought in by family or visitors. An Infection Preventionist found a plastic bag with a partially browned head of lettuce and two half-eaten sandwiches in the resident refrigerator, all unlabeled and undated. The Infection Preventionist confirmed these items should have been labeled with the resident's name and date, and could not determine how long the items had been stored.
The facility did not display the required State Survey Agency contact information and a statement about residents' rights to file complaints. A resident with moderate cognitive impairment was unaware of their rights due to this oversight. Interviews with staff, including a CNA and the DON, confirmed the absence of postings, and the Administrator acknowledged the failure in the facility's review process.
A facility failed to report a resident-to-resident abuse allegation within the required timeframe. An incident occurred where a resident reported being bumped by another resident, leading to police involvement. Despite the facility's policy requiring immediate reporting, the State Agency was not notified until several days later. Interviews revealed a lack of communication and understanding of the incident's severity among staff.
A resident was admitted with a diagnosis of psychosis and depression, but the facility failed to conduct a Level II PASRR as required. The resident's Level I PASRR did not identify any serious mental illness, and the diagnosis was missed during the admission process, particularly because it occurred over a weekend. Facility staff acknowledged the oversight in reviewing the resident's diagnosis and medications.
A resident with Alzheimer's Disease lost their custom-built hearing aids, and the facility failed to replace them in a timely manner. Instead, generic hearing aids were provided, which did not fit properly and were frequently lost. Observations confirmed the resident was without hearing aids and unable to communicate effectively. The request for replacement was still pending approval by management.
A resident in an LTC facility gave $740 to a CNA after the CNA expressed financial difficulties. The facility's policies prohibit such transactions, yet the CNA accepted the money, which was later returned in the presence of staff. This incident highlights a failure to protect the resident from financial exploitation.
A facility failed to implement a comprehensive care plan and follow physician orders for a resident with depression. The resident's care plan required administering Trazadone as ordered, but the MAR showed missing entries for monitoring depression and side effects, and the resident missed a dose. The DON and MRD acknowledged these issues but lacked documentation to confirm compliance with physician orders.
A facility failed to provide a resident's medical records in a timely manner to the resident's representative, despite a verbal and written request. The facility required a specific authorization form to be signed before releasing records, which was not aligned with their policy allowing access within 48 hours of a request. This resulted in a violation of the resident's rights.
A facility failed to implement a care plan intervention for a resident with a urinary tract infection, which required monitoring of intake and output. The Director of Nursing and Medical Records Director could not provide documentation that this intervention was carried out, despite the facility's policy requiring comprehensive, person-centered care plans with measurable objectives.
A facility failed to follow physician orders for catheter care for a resident, risking negative outcomes like urinary tract infections. The resident's Treatment Administration Record (TAR) showed missing entries for monitoring urine character and catheter placement over several months. This was confirmed by the DON and MRD during a review.
A resident did not receive a scheduled dose of Metoprolol due to a failure to follow physician orders and facility procedures. The resident's vital signs were within the parameters for administration, but the medication was withheld. The care plan required adherence to medication parameters, which was not followed, and the facility's documentation policy was not adhered to.
A facility failed to document the implementation of a fall prevention intervention for a resident with a history of falls and recent injuries. Despite having a care plan that required regular checks and assistance with toileting, there was no documentation to confirm these actions were carried out after the resident returned from the hospital. This oversight was identified during a review of the resident's medical record by the DON and Medical Records Director.
A facility failed to ensure timely monitoring and skin evaluation for a resident admitted after knee surgery. Despite orders to check for skin integrity, no assessments were documented until a deep tissue injury was found on the resident's heel two days after cast removal. The wound was later classified as stage IV.
A resident with a high risk of falling experienced an unwitnessed fall and subsequent hip fracture, but the facility failed to revise the care plan with new interventions. Despite an IDT meeting, the care plan remained unchanged until weeks later, contrary to the facility's policy.
Failure to Manage BiPAP Alarms, Oxygen Orders, and Required Respiratory Assessments
Penalty
Summary
The deficiency involves multiple failures in providing safe and appropriate respiratory care, including BiPAP management, oxygen administration, and required assessments and documentation. One resident with chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypoxia, and facioscapulohumeral muscular dystrophy was observed using a BiPAP machine that displayed a continuous leak alarm message for approximately 15–20 minutes without staff awareness or intervention. The BiPAP was positioned with the front facing the wall, and although the device was designed to beep when an air leak occurred, there was no audible alarm heard by the resident or staff. Nursing staff acknowledged the leak warning on the display and that the audible alarm was difficult to hear amid facility background noise. The respiratory therapist stated that alarms are intended to inform staff when there are issues with BiPAP function and that unattended leak alarms may mean the resident is not receiving the prescribed therapeutic dose. The same resident had physician orders for BiPAP use with oxygen at 2 LPM from 1 p.m. to 5 p.m. and again from 8 p.m. to 8 a.m., and for routine oxygen at 2 LPM via nasal cannula when not on BiPAP. During an observation, the resident was found on oxygen via nasal cannula and no longer on BiPAP during the ordered BiPAP treatment time. A nurse reported that the BiPAP continued to display an air leak that could not be resolved despite multiple mask adjustments and that the supplier had been contacted for troubleshooting. When asked for the BiPAP operator manual, staff could only produce the mask manual and confirmed that the operator manual was not available in the room or onsite, despite facility policy requiring staff to review and follow the manufacturer’s instructions for CPAP/BiPAP setup and oxygen delivery. Another nurse assigned to this resident stated they did not recall the resident being on BiPAP during the afternoon and believed the resident did not need BiPAP during those hours, and also stated that the BiPAP and oxygen orders were unclear. Review of the orders showed they were entered inaccurately, with oxygen ordered from 1 p.m. to 5 p.m. instead of 1 p.m. to 6 p.m., and the DON interpreted the orders to mean the resident should be without oxygen or BiPAP between 5 p.m. and 6 p.m., despite the written order stating routine oxygen when not on BiPAP. Additional deficiencies were identified in oxygen administration and required documentation for other residents. One resident’s oxygen concentrator was observed set at 1.5 LPM, while the electronic order specified 2 LPM via nasal cannula every shift; the RN confirmed the discrepancy. Another resident’s oxygen concentrator was initially read by a nurse as 4 LPM but, upon closer inspection at eye level, was found to be set at 3.5 LPM, while the order required 4 LPM. These findings occurred in the context of professional references stating that nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients, and that orders must be assessed and clarified if potentially erroneous or harmful. Finally, when asked for documentation of general assessments prior to BiPAP procedures, the DON could not provide it, despite facility policy requiring documentation of a general assessment (including vital signs, oxygen saturation, respiratory, circulatory, and gastrointestinal status) prior to CPAP/BiPAP procedures, as well as documentation of therapy times, settings, oxygen flow, tolerance, and oxygen saturation during therapy.
Improper Storage of Nebulizer Equipment Breaches Infection Control Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the storage of respiratory therapy equipment. During observation on 4/6/26 at 2:54 p.m., a nebulizer mask and tubing used for breathing treatments for Resident 1 were found placed uncovered on a shelf in the resident’s room. Review of the resident’s Medication Review Report dated 4/6/26 showed an order for ipratropium-albuterol inhalation solution via nebulizer, 3 mg/3 mL, every two hours as needed for chest congestion, confirming that this equipment was in active use for respiratory treatment. Resident 1’s Admission Record dated 4/2/26 documented diagnoses including COPD with acute exacerbation, acute and chronic respiratory failure with hypoxia, and facioscapulohumeral muscular dystrophy, and a BIMS score of 15, indicating no significant cognitive impairment. During a concurrent observation and interview on 4/6/26 at 3:25 p.m., a Licensed Vocational Nurse acknowledged that the nebulizer tubing and mask were on the shelf, uncovered, and not properly stored according to facility policy. Review of the facility’s February 2026 respiratory therapy infection prevention policy indicated that oxygen cannulas and tubing used PRN should be kept in a plastic bag when not in use, demonstrating that the observed storage of the nebulizer equipment did not comply with the written procedure. The report states this failure had the potential to result in cross-contamination and preventable HAIs for a resident in an already compromised condition.
Failure to Notify Resident Representative of Rescheduled Medical Appointment
Penalty
Summary
The facility failed to notify the resident representative (RR) of a rescheduled medical appointment for one of two sampled residents, as required by their own policy. The RR reported that an appointment with a cardiovascular physician was changed by the provider, but the facility did not inform the RR, resulting in the RR being unable to attend the appointment. Review of the resident's progress notes showed documentation of the original and updated appointment dates, but there was no indication that the RR was notified of the change. The facility's policy on transporting residents to appointments specifies that the resident and/or responsible party will be notified of pending appointments and necessary transportation arrangements. During an interview, the Social Services Director confirmed that the RR should have been notified and acknowledged that the progress notes did not reflect such notification.
Plan Of Correction
A. What corrective action(s) will be accomplished for the patient(s) identified to have been affected by the deficient practice. It was documented in Resident 1's medical record that on 09/25/25, D.O.N. reviewed with resident's son (Michael) the findings and recommendations of the 9/24/25 vascular appointment. He did not have any issues. Resident 1 was discharged to an Independent Living Facility on 11/7/25 in stable condition and with no negative outcome. B. How other patients having the potential to be affected by the same deficient practice will be identified, and what corrective action will be taken. On 11/6/25, D.O.N. reviewed all scheduled appointments for the month of November. There are no issues on resident and/or responsible party notification of the appointment. C. What immediate measures and systemic changes will be put into place to ensure that the deficient practice does not recur. On 11/5/25 and 11/6/25, DON conducted an in-service to the licensed nurses and department managers to review the policy and procedure on "Resident's Appointments". Social Service staff will inform the resident, responsible party (if applicable), and nurses for any change in the appointment schedule. Social Service staff and Nursing will utilize the Scheduled Appointment Information form as a source of communication. D. How the facility plans to monitor its performance to ensure corrections are achieved and sustained. The plan of correction must be implemented, corrective action evaluated for its effectiveness, and it must be integrated into the quality assurance system. On 11/6/25, a QAPI Plan "Resident's Appointment Notification" was initiated by the IDT. Medical records will audit MD orders daily 5x/week to ensure that the resident and/or responsible party are notified of the appointments and documented in the record. D.O.N. and Administrator will be given a copy of the audit to ensure compliance. Findings of the audit will be discussed during the QAPI Committee meeting monthly x3 then quarterly and follow their recommendation for continued compliance. E. Dates when corrective action will be completed: November 11, 2025
Unsanitary and Unsafe Shower Room Conditions
Penalty
Summary
A shower room located in hallway four was found to be unsanitary and in disrepair during an inspection conducted with the Maintenance Director. Observations included a shower doorframe in a state of disrepair, broken wall tiles, and a call light cord that was broken and had been replaced with plastic bags instead of a proper replacement. Additionally, a bottle of lotion was stored on top of a dirty sharps container, and a used razor was found in a plastic cup placed atop a box of clean gloves. The Maintenance Director confirmed these findings during the inspection. Review of the facility's policy indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not maintained in this instance.
Failure to Adhere to Food Storage and Labeling Policy for Resident Food Brought by Visitors
Penalty
Summary
Facility staff failed to follow the established policy and procedure regarding the storage and labeling of foods brought in by family and visitors for residents. During an inspection of the resident refrigerator, an Infection Preventionist observed an unlabeled and undated plastic bag containing a partially browned head of lettuce and two half-eaten sandwiches in plastic containers, also unlabeled and undated. The Infection Preventionist confirmed that these items should have been labeled with the resident's name and date, as per facility policy. When questioned, the Infection Preventionist was unable to determine how long the items had been in the refrigerator, though stated that the facility practice was to clean out the refrigerator weekly. Review of the facility's policy indicated that perishable foods must be stored in resealable containers with tightly fitting lids, labeled with the resident's name, item, and use-by date, and that staff are responsible for discarding foods showing signs of potential foodborne danger.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to comply with federal posting requirements by not displaying the State Survey Agency contact information and a statement regarding residents' rights to file a complaint. This deficiency was identified during an observation of the facility's bulletin board, which lacked the necessary postings. The facility's policy, titled 'Federal Posting Policy,' mandates the display of such information in publicly accessible areas to inform residents, employees, and visitors of their rights under federal law. However, the absence of this information was confirmed through interviews with a resident, a CNA, the DON, and the Administrator, all of whom acknowledged the lack of required postings. A resident with moderate cognitive impairment, as indicated by a BIMS score of 12, was unaware of their right to file a complaint with the state agency due to the absence of the necessary information. The CNA and the DON also confirmed the lack of awareness and absence of postings. The Administrator admitted that the facility's monthly review process failed to ensure the required information was posted, acknowledging the oversight and expressing an expectation that all necessary data should be displayed.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident-to-resident abuse allegation to the State Agency within the required two-hour timeframe. On January 27, 2025, an incident occurred where Resident #39 reported that Resident #7 bumped into their wheelchair and knee. The police were called by Resident #39, but the facility did not notify the State Agency of the incident until February 5, 2025. The facility's policy mandates that any suspected abuse must be reported immediately or within 24 hours, but this protocol was not followed. Resident #39, who was admitted to the facility in 2019, has a medical history that includes depression and a traumatic brain injury. The resident reported feeling unsafe after the incident, although they were not physically hurt. Resident #7, admitted in 2021, has a history of chronic pain syndrome and bipolar disorder. Both residents have intact cognition as indicated by their BIMS scores. The facility's care plans for both residents were updated on February 4, 2025, to address the risk of emotional distress due to the disagreement. Interviews with staff revealed a lack of communication and understanding of the incident's severity. The Director of Nursing and Operations Manager were informed of a verbal disagreement but not of any physical contact. The Administrator was aware of the police presence but did not report the incident to the State Agency, relying on the police's assessment that no crime occurred. This oversight led to a delay in reporting the abuse allegation, violating the facility's policy and state regulations.
Failure to Conduct Level II PASRR for Resident with Psychosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASRR) despite the resident being admitted with a diagnosis of psychosis and depression. The facility's policy requires verification of a Level I PASRR screen for potential admissions to determine if a Level II screening is necessary. However, the resident's Level I PASRR screening did not identify any serious mental illness, and the resident was admitted without a Level II screening. The resident's medical history included unspecified psychosis and depression, and the resident was on antipsychotic and antidepressant medications. Interviews with facility staff revealed that the PASRR process was not followed correctly. The Admission Director and MDS Coordinator both acknowledged that the diagnosis of psychosis was missed during the admission process, particularly because the admission occurred over a weekend. The Director of Nursing and the Administrator confirmed that the admissions staff are responsible for reviewing new admissions to determine if a Level II screening is required, but the diagnosis of psychosis was overlooked in this case.
Failure to Replace Lost Custom-Built Hearing Aids
Penalty
Summary
The facility failed to uphold the resident's right to be treated with respect and dignity by not replacing custom-built hearing aids for a resident in a timely manner. The resident, who was admitted with Alzheimer's Disease, had custom-built hearing aids documented in their inventory of personal effects upon admission. However, these hearing aids were lost in July of the previous year, and the facility provided generic hearing aids that were ill-fitting and frequently fell off, leading to further loss. Interviews and observations revealed that the resident was without hearing aids, unable to hear or understand questions, and the request for replacement hearing aids was still pending approval by upper management. The operations manager acknowledged awareness of the situation and agreed that the resident's quality of life could be affected by the inability to hear, which impedes effective communication between the resident and staff.
Misappropriation of Resident's Money by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically involving a financial transaction with a Certified Nursing Assistant (CNA). The incident involved a resident who provided $740 to a CNA after the CNA expressed financial difficulties related to car and bill troubles. The resident and the CNA had an agreement that the money would be repaid by a certain date. This transaction was reported by the resident to the activities staff, and the CNA later returned the money to the resident in the presence of the Director of Staff Development and the Concierge. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention clearly states that residents have the right to be free from such actions. Additionally, the facility's policy on gifts, gratuities, and payments prohibits employees from engaging in activities that conflict with the interests of the facility or its residents. Despite these policies, the incident occurred, indicating a failure to adhere to the established guidelines designed to protect residents from financial exploitation.
Failure to Implement Comprehensive Care Plan and Follow Physician Orders
Penalty
Summary
The facility failed to implement a comprehensive care plan and follow physician orders for a resident diagnosed with depression, who required antidepressant medication. The care plan included an intervention to administer the antidepressant medication, Trazadone, as ordered by the physician. However, during a review of the resident's medication administration record (MAR), it was found that there were missing entries for monitoring the resident for episodes of depression and adverse side effects of Trazadone on two separate occasions. Additionally, the resident did not receive the prescribed two doses of Trazadone on one occasion, receiving only one dose instead. The Director of Nursing and Medical Records Director acknowledged the missing entries and the failure to administer the medication as ordered, but could not provide additional documentation to indicate that the physician's orders were carried out on the specified dates. The facility's policy on comprehensive, person-centered care plans emphasizes the development and implementation of a care plan for each resident to maintain their highest practicable physical, mental, and psychosocial well-being. The failure to adhere to this policy and the physician's orders had the potential to negatively impact the resident.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide requested medical records in a timely manner to a resident's representative, violating the resident's rights. The representative of the resident made a verbal and written request for the resident's medical records on October 3, 2024. However, the facility did not fulfill this request because the representative had not signed the facility's specific authorization form titled 'Authorization Form For The Release of Health Information.' As of November 4, 2024, the requested medical records had not been provided to the resident's representative. Interviews with the Social Services Director, Director of Nursing, and Medical Records Director revealed that the facility's policy required the signing of their specific authorization form before releasing medical records, even if a verbal or written request had been made. This practice was contrary to the facility's policy and procedure titled 'Resident Rights,' which stated that residents have the right to access personal information and medical records. Additionally, the facility's 'Release of Information' policy indicated that residents could access their records within 48 hours of a written or oral request, excluding weekends and holidays. The facility's failure to adhere to these policies resulted in the deficiency.
Failure to Implement Care Plan for Monitoring Intake and Output
Penalty
Summary
The facility failed to adhere to a care plan intervention for a resident who had a urinary tract infection. The care plan, which was undated, required staff to monitor the resident's intake and output. However, during a review of the resident's care plan, the Director of Nursing and the Medical Records Director were unable to provide documentation that this intervention was carried out by the staff. The facility's policy on comprehensive, person-centered care plans, dated 2001, mandates that such plans include measurable objectives and timetables to meet the resident's needs. Despite this policy, the lack of documentation indicates that the care plan intervention was not implemented as required, potentially leading to negative outcomes for the resident.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to adhere to physician orders for catheter care for one resident, which had the potential to lead to negative outcomes such as an increased risk of urinary tract infections. During a review of the Treatment Administration Record (TAR) for the resident, it was found that there were missing or blank entries on multiple dates between May and August. The physician orders required monitoring of urine character and ensuring proper placement of the catheter to prevent obstruction of urine flow every shift. However, the TAR showed that these orders were not consistently documented, as confirmed by the Director of Nursing and the Medical Records Director during the review.
Failure to Administer Metoprolol as Ordered
Penalty
Summary
The facility failed to administer Metoprolol, a medication used to treat high blood pressure, according to physician orders for one of the sampled residents. The deficiency was identified during a record review and interview with the Director of Nursing and Medical Records Director. The resident's Medication Administration Record (MAR) indicated a physician order for Metoprolol to be given twice daily, with specific parameters for withholding the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60 beats per minute. On a specific date, the resident did not receive the scheduled dose of Metoprolol because the vital signs were incorrectly assessed as being outside the parameters, despite the recorded blood pressure and heart rate being within the acceptable range. The resident's care plan required adherence to the parameters for holding medication as ordered, which was not followed in this instance. The facility's policy and procedure for documentation of medication administration required documentation of reasons for withholding medication, which was not appropriately adhered to. The Director of Nursing and Medical Records Director acknowledged that the resident should have received the scheduled dose of Metoprolol based on the documented vital signs, indicating a failure in following the physician's orders and the facility's procedures.
Failure to Document Fall Prevention Intervention
Penalty
Summary
The facility failed to document the implementation of a care plan intervention for a resident who was at risk for falls. The resident, who had a history of falls and was diagnosed with an acute fracture of the right 8th and 9th ribs, head injury, and scalp laceration, was found sitting on a landing mat after falling while attempting to use the commode. The resident reported pain in the head and rib area and had a history of falling with a displaced fracture of the left clavicle, incontinence, lack of coordination, muscle weakness, and an unsteady gait. The care plan for the resident included an intervention to check the resident at least every two hours and as needed to assist with toileting. However, during a review of the resident's medical record, the Director of Nursing and Medical Records Director could not provide documentation that this intervention was carried out after the resident returned from the hospital. The facility's policies on comprehensive person-centered care plans and fall risk management emphasize the need for measurable objectives and monitoring of interventions, but the lack of documentation indicates a failure to adhere to these policies.
Failure to Monitor and Evaluate Resident's Skin Condition
Penalty
Summary
The facility failed to ensure timely monitoring and skin evaluation for a resident who was admitted following right knee surgery. The resident had a cast from the thigh to the foot, which was later replaced with a knee immobilizer. Despite physician orders to check for circulation, skin integrity, and signs of infection, the facility did not document any skin assessments until a deep tissue injury was discovered on the resident's right heel two days after the cast removal. The treatment nurse confirmed that there was no follow-up communication from the orthopedic doctor's office, and no additional orders were checked or documented. The wound consultant assessed the resident's right heel and found an unstageable injury, which was later debrided and classified as a stage IV wound. The consultant noted that such injuries could develop within a few hours due to pressure on a bony structure like the heel, especially given the resident's high-risk factors and limited mobility. The facility's policy indicated that any notable changes in the resident's condition should be documented, but this was not followed, leading to a delay in identifying and treating the pressure ulcer.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall incident. The resident, who was admitted with diagnoses including Dementia, Anxiety, and Unsteadiness on Feet, had a history of fluctuating capacity to understand and make decisions and was assessed as having a high risk of falling. Despite an unwitnessed fall on 3/8/24 and a subsequent hip fracture discovered on 3/16/24, the care plan interventions remained unchanged from before the fall incident. This was confirmed during a review of the fall care plans dated 3/1/24 and 3/9/24, which showed similar interventions. The Nurse Supervisor acknowledged that the interventions should have been revised after the fall incident. Further interviews revealed that additional interventions were only added on 4/4/24, well after the fall incident. The Minimum Data Set (MDS) coordinator confirmed that an IDT meeting was held on 3/9/24 to address the fall, but the care plan was not updated to include new interventions. The facility's policy and procedure on care plans indicated that interventions should be derived from comprehensive assessments and input from the resident and their family, which was not adhered to in this case.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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